Provider Demographics
NPI:1881047447
Name:TACKETT, MARY ANN (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1791 ALUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-1708
Mailing Address - Country:US
Mailing Address - Phone:614-445-8131
Mailing Address - Fax:614-827-8380
Practice Address - Street 1:88 N. SANDUSKY ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015
Practice Address - Country:US
Practice Address - Phone:740-203-3800
Practice Address - Fax:740-203-3799
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN127169-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse